Journal of Research in Medical Sciences : The Official

Journal of Isfahan University of Medical Sciences

Wolters Kluwer -- Medknow Publications

Effects of air pollution on human health and practical

measures for prevention in Iran
Adel Ghorani-Azam, Bamdad Riahi-Zanjani, and Mahdi Balali-Mood
Additional article information

Abstract
Air pollution is a major concern of new civilized world, which has a serious
toxicological impact on human health and the environment. It has a number of
different emission sources, but motor vehicles and industrial processes contribute
the major part of air pollution. According to the World Health Organization, six
major air pollutants include particle pollution, ground-level ozone, carbon
monoxide, sulfur oxides, nitrogen oxides, and lead. Long and short term exposure
to air suspended toxicants has a different toxicological impact on human including
respiratory and cardiovascular diseases, neuropsychiatric complications, the eyes
irritation, skin diseases, and long-term chronic diseases such as cancer. Several
reports have revealed the direct association between exposure to the poor air
quality and increasing rate of morbidity and mortality mostly due to cardiovascular
and respiratory diseases. Air pollution is considered as the major environmental
risk factor in the incidence and progression of some diseases such as asthma, lung
cancer, ventricular hypertrophy, Alzheimer's and Parkinson's diseases,
psychological complications, autism, retinopathy, fetal growth, and low birth
weight. In this review article, we aimed to discuss toxicology of major air
pollutants, sources of emission, and their impact on human health. We have also
proposed practical measures to reduce air pollution in Iran.
Keywords: Air pollution, cardiovascular diseases, environment, human health,
respiratory tract diseases, toxicology
INTRODUCTION
Air pollution is a major problem of recent decades, which has a serious
toxicological impact on human health and the environment. The sources of
pollution vary from small unit of cigarettes and natural sources such as volcanic
activities to large volume of emission from motor engines of automobiles and
industrial activities.[1,2] Long-term effects of air pollution on the onset of diseases
such as respiratory infections and inflammations, cardiovascular dysfunctions, and
cancer is widely accepted;[3,4,5,6] hence, air pollution is linked with millions of
death globally each year.[7,8,9] A recent study has revealed the association
between male infertility and air pollution.[10]
Air pollution has now emerged in developing countries as a result of industrial
activities and also increase the quantity of emission sources such as inappropriate
vehicles.[11,12,13] About 4.3 million people die from household air pollution and
3.7 million from ambient air pollution, most of whom (3.3 and 2.6 million,
respectively) live in Asia.[14] In Iran, as a developing country, the level of air
pollutants has increased gradually since the beginning of industrialization in the
1970s, but it has reached a very harmful level in some megacities such as Tehran,
Mashhad, Tabriz, Isfahan, Ahvaz, Arak, and Karaj over the past two decades. Iran
is the world's third main polluted country in the world, which results in 16 billion $
annual loss.[15] In fact, four of the top ten air-polluted cities are in Iran. Ahvaz is
the most air polluted city in the world with microdust blowing in from neighboring
countries, and particulate levels three times that of Beijing, and nearly 13 times
that of London.[16] Air pollution caused almost 4460 deaths in 2013 only in
Tehran although the reality seemed higher and is getting worse every year.[17]
Therefore, it is of great importance to describe the problem, particularly its toxic
effects on human health and provide recommendations as a basis for environmental
guidelines and standard protocols in the field of air pollution in Iran.
The present article is neither a systematic review nor a descriptive, educational
study. It is a problem-based descriptive review in which the authors try to explain a
problem which is the major health and ecological problem in developing countries
like Iran. In this review, we have tried to summarize the toxicology of air
pollutants and related diseases with a possible mechanism of action and
appropriate management of the patients. Therefore, it shall be useful for the
environmental and health professionals particularly policy makers, emergency
physicians, and other clinicians who may be involved in air pollution and related
diseases. In this paper, we also discuss sources of air pollution and proposed some
feasible solutions which may be beneficial for the environmental legislators and
decision makers.

DEFINITIONS
Air pollution is defined as all destructive effects of any sources which contribute to
the pollution of the atmosphere and/or deterioration of the ecosystem. Air pollution
is caused by both human interventions and/or natural phenomena. It is made up of
many kinds of pollutants including materials in solid, liquid, and gas phases.[18]
Air pollutions of indoors will not be specifically considered in this article.
The Pollutant Standard Index (PSI) is a numerical value and indicator of pollutants
that is normally used to facilitate risk assessment. It is a numeric value between
zero to 500.[19] PSI is a guideline for reporting air quality which was first
introduced by Thom and Ott in 1974.[20] Hence, it would provide a method of
comparing the relative contribution of each pollutant to total risk.[21] The
calculation of PSI is based on the concentration of five major air pollutants
including particulate matters (PMs), sulfur dioxide (SO2), nitrogen dioxide (NO2),
carbon monoxide (CO), and ozone (O3) in the air.
According to Johnson et al., “air quality index (AQI) is defined as a measure of the
condition of air relative to the requirements of one or more biotic species or to any
human need.”[22] AQI is divided into ranges, in which they are numbered, and
each range is marked with color codes. It provides a number from healthy standard
level of zero to a very hazardous level of above 300 to indicate the level of health
risk associated with air quality. Based on PSI, air quality is classified into six
major indices, which is marked by color codes and each color corresponds to a
different level of health concerns. Principally, green is defined as a color indicator
for healthy air quality; while yellow, orange, red, purple, and maroon colors
indicate as moderate, unhealthy for sensitive groups, unhealthy, very unhealthy,
and hazardous air quality, respectively. These ranges and codes may differ in the
different methods of classifications in different countries.[22]

TOXICOLOGY OF AIR POLLUTION

Effects of air pollutants on living organism will not only be limited to the human
and animal health but also include the whole environment. Different geographical
conditions, global climate changes, and the environmental variations affect the
human health and the environment including the animal life.
Environmental damages
Ecologically, air pollution can cause serious environmental damages to the
groundwater, soil, and air.[23,24] It is also a serious threat to the diversity of life.
Studies on the relationship between air pollution and reducing species diversity
clearly show the detrimental effects of environmental contaminants on the
extinction of animals and plants species.[25] Air suspended toxicants may also
cause reproductive effects in animals.[26,27] Acid rain, temperature inversion, and
global climate changes due to the emissions of greenhouse gasses to the
atmosphere are other major ecological impacts of air pollution.[28]

Air pollutants and their toxicities

Every material in the air which could affect human health or have a profound
impact on the environment is defined as air pollutants. According to the World
Health Organization (WHO), particle pollution, ground-level O3, CO, sulfur
oxides, nitrogen oxides, and lead (Pb) are the six major air pollutants which harm
human health and also the ecosystem. There are many pollutants of suspended
materials such as dust, fumes, smokes, mists, gaseous pollutants, hydrocarbons,
volatile organic compounds (VOCs), polycyclic aromatic hydrocarbons (PAHs),
and halogen derivatives in the air which at the high concentrations cause
vulnerability to many diseases including different types of cancers.[29,30,31,32]
The most important air pollutants and their toxic effects on different human body
organs and related diseases have been briefly described below.

Particle pollutants
Particle pollutants are major parts of air pollutants. In a simple definition, they are
a mixture of particles found in the air. Particle pollution which is more known as
PM is linked with most of pulmonary and cardiac-associated morbidity and
mortality.[33,34] They have varied in size ranging mostly from 2.5 to 10 μm
(PM2.5 to PM10).
The size of particle pollutants is directly associated with the onset and progression
of the lungs and heart diseases. Particles of smaller size reach the lower respiratory
tract and thus have greater potential for causing the lungs and heart diseases.
Moreover, numerous scientific data have demonstrated that fine particle pollutants
cause premature death in people with heart and/or lung disease including cardiac
dysrhythmias, nonfatal heart attacks, aggravated asthma, and decreased lung
functions. Depending on the level of exposure, particulate pollutants may cause
mild to severe illnesses. Wheezing, cough, dry mouth, and limitation in activities
due to breathing problems are the most prevalent clinical symptoms of respiratory
disease resulted from air pollution.[35,36,37]
Long-term exposure to current ambient PM concentrations may lead to a marked
reduction in life expectancy. The increase of cardiopulmonary and lung cancer
mortality are the main reasons for the reduction in life expectancy. Reduced lung
functions in children and adults leading to asthmatic bronchitis and chronic
obstructive pulmonary disease (COPD) are also serious diseases which induce
lower quality of life and reduced life expectancy. Strong evidence on the effect of
long-term exposure to PM on cardiovascular and cardiopulmonary mortality come
from cohort studies.[38,39,40]

Ground-level ozone
O3 with the chemical formula of O3 is a colorless gas which is the major constituent
of the atmosphere. It is found both at the ground level and in the upper regions of
the atmosphere which is called troposphere. Ground-level ozone (GLO) is
produced as a result of chemical reaction between oxides of nitrogen and VOCs
emitted from natural sources and/or due to human activities. GLO is believed to
have a plausible association with increased risk of respiratory diseases, particularly
asthma.[41]
As a powerful oxidant, O3 accepts electrons from other molecules. There is a high
level of polyunsaturated fatty acids in the surface fluid lining of the respiratory
tract and cell membranes that underlie the lining fluid. The double bonds available
in these fatty acids are unstable. O3 attacks unpaired electron to form ozonides and
progress through an unstable zwitterion or trioxolane (depending on the presence
of water). These ultimately recombine or decompose to lipohydroperoxides,
aldehydes, and hydrogen peroxide. These pathways are thought to initiate
propagation of lipid radicals and auto-oxidation of cell membranes and
macromolecules. It also increases the risk of DNA damage in epidermal
keratinocytes, which leads to impaired cellular function.[42]
O3 induces a variety of toxic effects in humans and experimental animals at
concentrations that occur in many urban areas.[43] These effects include
morphologic, functional, immunologic, and biochemical alterations. Because of its
low water solubility, a substantial portion of inhaled O3 penetrates deep into the
lungs but its reactivity is scrubbed by the nasopharynx of resting rats and humans
in around 17% and 40%, respectively.[44,45] On ecological aspect, O3 can reduce
carbon assimilation in trees leading to deforestation which may affect global food
security in long-term exposure.[46,47]

Carbon monoxide
CO is a colorless and odorless gas, which is produced by fossil fuel, particularly
when combustion is not appropriate, as in burning coal and wood. The affinity of
CO to hemoglobin (as an oxygen carrier in the body) is about 250 times greater
than that of oxygen. Depending on CO concentration and length of exposure, mild
to severe poisoning may occur. Symptoms of CO poisoning may include headache,
dizziness, weakness, nausea, vomiting, and finally loss of consciousness. The
symptoms are very similar to those of other illnesses, such as food poisoning or
viral infections.
No human health effects have been showed for carboxyhemoglobin (COHb) levels
lower than 2%, while levels above 40% may be fatal. Hypoxia, apoptosis, and
ischemia are known mechanisms of underlying CO toxicity.[48] The mechanism of
such toxicity is the loss of oxygen due to competitive binding of CO to the
hemoglobin heme groups. Cardiovascular changes also may be observed by CO
exposures that create COHb in excess of 5%. In the early 1990s, Health Effects
Institute performed a series of studies associated with cardiovascular disease to
determine the potential for angina pectoris with COHb levels in the range of 2–6%.
[49] The results showed that premature angina can occur under these situations but
that the potential for the occurrence of ventricular arrhythmias remains uncertain.
Thus, the reduction in ambient CO can reduce the risk of myocardial infarction in
predisposed persons.

Sulfur dioxide
SO2 is a colorless, highly reactive gas, which is considered as an important air
pollutant. It is mostly emitted from fossil fuel consumption, natural volcanic
activities, and industrial processes. SO2 is very harmful for plant life, animal, and
human health. People with lung disease, children, older people, and those who are
more exposed to SO2 are at higher risk of the skin and lung diseases.
The major health concerns associated with exposure to high concentrations of
SO2 include respiratory irritation and dysfunction, and also aggravation of existing
cardiovascular disease. SO2 is predominantly absorbed in the upper airways. As a
sensory irritant, it can cause bronchospasm and mucus secretion in humans.
Residents of industrialized regions encountered with SO2 even at lower
concentrations (<1 ppm) in the polluted ambient air might experience a high level
of bronchitis.
The penetration of SO2 into the lungs is greater during mouth breathing compared
to nose breathing. An increase in the airflow in deep, rapid breathing enhances
penetration of the gas into the deeper lung. Therefore, people who exercise in the
polluted air would inhale more SO2 and are likely to suffer from greater irritation.
When SO2 deposits along the airway, it dissolves into surface lining fluid as sulfite
or bisulfite and is easily distributed throughout the body. It seems that the sulfite
interacts with sensory receptors in the airways to cause local and centrally
mediated bronchoconstriction.
According to the Environmental Protection Agency (EPA) of the USA, the level of
annual standard for SO2 is 0.03 ppm. Due to its solubility in water, SO2 is
responsible for acid rain formation and acidification of soils. SO2 reduces the
amount of oxygen in the water causing the death of marine species including both
animals and plants. Exposure to SO2 can cause damages to the eyes (lacrimation
and corneal opacity), mucous membranes, the skin (redness, and blisters), and
respiratory tracts. Bronchospasm, pulmonary edema, pneumonitis, and acute
airway obstruction are the most common clinical findings associated with exposure
to SO2.[50]

Nitrogen oxide
Nitrogen oxides are important ambient air pollutants which may increase the risk
of respiratory infections.[50] They are mainly emitted from motor engines and thus
are traffic-related air pollutants. They are deep lung irritants that can induce
pulmonary edema if been inhaled at high levels. They are generally less toxic than
O3, but NO2 can pose clear toxicological problems. Exposures at 2.0–5.0 ppm have
been shown to affect T-lymphocytes, particularly CD8+ cells and natural killer cells
that play an important role in host defenses against viruses. Although these levels
may be high, epidemiologic studies demonstrate effects of NO2 on respiratory
infection rates in children.
Coughing and wheezing are the most common complication of nitrogen oxides
toxicity, but the eyes, nose or throat irritations, headache, dyspnea, chest pain,
diaphoresis, fever, bronchospasm, and pulmonary edema may also occur. In
another report, it is suggested that the level of nitrogen oxide between 0.2 and 0.6
ppm is harmless for the human population.[51]
Lead
Pb or plumb is a toxic heavy metal that is widely used in different industries.[52]
Pb pollution may result from both indoor and outdoor sources. It is emitted from
motor engines, particularly with those using petrol containing Pb tetraethyl.
Smelters and battery plants, as well as irrigation water wells and wastewaters, are
other emission sources of the Pb into the environment.[52,53] Evaluation of the
blood Pb level in traffic police officers shows that environmental pollution may be
considered as a source of Pb exposure.[54] Fetuses and children are highly
susceptible to even low doses of Pb.[55] Pb accumulates in the body in blood,
bone, and soft tissue. Because it is not readily excreted, Pb can also affect the
kidneys, liver, nervous system, and the other organs.[56]
Pb absorption by the lungs depends on the particle size and concentration. Around
90% of Pb particles in the ambient air that are inhaled are small enough to be
retained. Retained Pb absorption through alveoli is absorbed and induces toxicity.
Pb is a powerful neurotoxicant, especially for infants and children as the high-risk
groups. Mental retardation, learning disabilities, impairment of memory,
hyperactivity, and antisocial behaviors are of adverse effects of Pb in childhood.
[57,58] Therefore, it is very important to reduce the Pb level of ambient air.[59]
Pb exposure is often chronic, without obvious symptoms.[60] It can affect the
different parts of the body including cardiovascular, renal, and reproductive
systems, but the main target for Pb toxicity is the nervous system.[61] Pb disrupts
the normal function of intracellular second messenger systems through the
inhibition of N-methyl-D-aspartate receptors. Pb may also replace calcium as a
second messenger resulting in protein modification through various cellular
processes including protein kinase activation or deactivation.
Abdominal pain, anemia, aggression, constipation, headaches, irritability, loss of
concentration and memory, reduced sensations, and sleep disorders are the most
common symptoms of Pb poisoning. Exposure to Pb is manifested with numerous
problems, such as high blood pressure, infertility, digestive and renal, and muscle
and joint pain. dysfunctions

Other air pollutants

Other major air pollutants that are classified as carcinogen and mutagen
compounds and are thought to be responsible for incidence and progression of
cancer in human include VOCs such as benzene, toluene, ethylbenzene, and
xylene, PAHs such as acenaphthene, acenaphthylene, anthracene, and
benzopyrene, and other organic pollutants such as dioxins, which are unwanted
chemical pollutants that almost totally produced by industrial processes and human
activity.[62,63,64]
In Table 1, the standard level of some conventional air pollutants is presented in
which the values were defined as air quality standards that provide public welfare
protection.

Table 1
Standard level of criteria air pollutants and their sources with health impact based
on the United States Environmental Protection Agency

As it can be easily understood, fossil fuel consumption shares the largest part of air
contamination. Air pollutants can also be classified into anthropogenic and natural
according to their source of emission. From anthropogenic aspect, air
contamination occurs from industrial and agricultural activities, transportation, and
energy acquisition. While from natural contaminant has different sources of
emission such as volcanic activities, forest fire, sea water, and so on.[65,66]

Health hazards
In terms of health hazards, every unusual suspended material in the air, which
causes difficulties in normal function of the human organs, is defined as air
toxicants. According to available data, the main toxic effects of exposure to air
pollutants are mainly on the respiratory, cardiovascular, ophthalmologic,
dermatologic, neuropsychiatric, hematologic, immunologic, and reproductive
systems. However, the molecular and cell toxicity may also induce a variety of
cancers in the long term.[67,68] On the other hand, even small amount of air
toxicants is shown to be dangerous for susceptible groups including children and
elderly people as well as patients suffering from respiratory and cardiovascular
diseases.[69]
Respiratory disorders
Because most of the pollutants enter the body through the airways, the respiratory
system is in the first line of battle in the onset and progression of diseases resulted
from air pollutants. Depending on the dose of inhaled pollutants, and deposition in
target cells, they cause a different level of damages in the respiratory system. In the
upper respiratory tract, the first effect is irritation, especially in trachea which
induces voice disturbances. Air pollution is also considered as the major
environmental risk factor for some respiratory diseases such as asthma and lung
cancer.[70,71] Air pollutants, especially PMs and other respirable chemicals such
as dust, O3, and benzene cause serious damage to the respiratory tract.
[72,73,74,75,76,77] Asthma is a respiratory disease which may be developed as a
result of exposure to air toxicants.[78] Some studies have validated associations
between both traffic-related and/or industrial air pollution and increasing the risk
of COPD.[79,80,81] Treatment of respiratory diseases due to air pollution is
similar to the other toxic chemical induce respiratory disorders.

Cardiovascular dysfunctions
Many experimental and epidemiologic studies have shown the direct association of
air pollutant exposure and cardiac-related illnesses.[82,83,84,85] Air pollution is
also associated with changes in white blood cell counts[86] which also may affect
the cardiovascular functions. On the other hand, a study on animal models
suggested the close relationship between hypertension and air pollution exposure.
[87] The traffic-related air pollution, especially exposure to high levels of NO2, is
associated with right and left ventricular hypertrophy.[88,89] In addition to the
antidote therapy that exists only for a few cardiotoxic substances like CO, usual
treatment of cardiovascular diseases should be carried out.

Neuropsychiatric complications
The relationship between exposure to air suspended toxic materials and nerve
system has always been argued. However, it is now believed that these toxic
substances have damaging effects on the nervous system. The toxic effect of air
pollutants on nerve system includes neurological complications and psychiatric
disorders. Neurological impairment may cause devastating consequences,
especially in infants. In contrast, psychiatric disorders will induce aggression and
antisocial behaviors. Recent studies have reported the relationship between air
pollution and neurobehavioral hyperactivity, criminal activity, and age-
inappropriate behaviors.[90,91] Studies have also revealed the association between
air pollution and higher risk of neuroinflammation,[92] Alzheimer's and
Parkinson's diseases.[93] Some studies showed that aggression and anxiety in
megacities are in close relationship with the high level of air pollutants.[94,95,96]

Other long-term complications

Skin is the body's first line of defense against a foreign pathogen or infectious
agent and it is the first organ that may be contaminated by a pollutant. The skin is a
target organ for pollution in which the absorption of environmental pollutants from
this organ is equivalent to the respiratory uptake.[97] Research on the skin has
provided evidence that traffic-related air pollutants, especially PAHs, VOCs,
oxides, and PM affect skin aging and cause pigmented spots on the face.
[98,99,100]
Theoretically, toxic air pollutants can cause damage to organs when inhaled or
absorbed through the skin.[101] Some of these pollutants are hepatocarcinogen
chemicals.[102,103] There are some proven data which highlighted the role of air
pollutants, especially traffic-related air pollution on the incidence of autism and its
related disorders in fetus and children.[104,105,106,107] Disrupting endocrine by
chemical components of pollutants has been described as a possible mechanistic
pathway of autism or other neurological disorders.[93,108] Some studies showed
that there are relationships between air pollution exposure and fetal head size in
late pregnancy,[109] fetal growth,[110] and low birth weight.[111,112]
Many of the diseases that are linked to immune system dysfunction can be affected
by several environmental factors such as poor air quality.[113,114] Poor air quality
can cause serious complications in the immune system such as an abnormal
increase in the serum levels of the immunoglobulin (Ig); IgA, IgM, and the
complement component C3 in humans as well as chronic inflammatory diseases of
the respiratory system.[115] Exposure to these immunotoxicants may also cause
immune dysfunction at different stages which can serve as the basis for increased
risks of numerous diseases such as neuroinflammation, an altered brain innate
immune response.[93,116] Air pollutants modify antigen presentation by up-
regulation of costimulatory molecules such as CD80 and CD86 on macrophages.
[117]
The eye is a neglected vulnerable organ to the adverse effects of air suspended
contaminants even household air pollution.[118,119] Clinical effects of air
pollution on the eyes can vary from asymptomatic eye problems to dry eye
syndrome. Chronic exposure to air pollutants increases the risk for retinopathy and
adverse ocular outcomes. In addition, there are now evidence suggesting the
association between air pollution and irritation of the eyes, dry eye syndrome, and
some of the major blinding.[118,120] According to data, the level of air pollution
is linked to short-term increases in the number of people visiting the
ophthalmological emergency department.[121,122]

Air pollution in Iran

Air pollution in Iran as a developing country has recently caused several health and
environmental problem. According to a report, the quality of air in Iran, especially
in Tehran metropolis is very unhealthy and most of the pollution indices,
specifically indices for CO and PM are above the standard and at sometimes at
dangerous level.[123] Nonstandard motor engines and other traffic-related sources
of air pollution are the most important cause of poor air quality. For example, more
than 90% of the CO gas as an important air pollutant is generated by motor
vehicles in Tehran.[124] Moreover, reports have shown that more than 80% of air
pollution in Iran is attributed to motor vehicles.[125,126] Official reports show that
in Tehran, 9.4% of the cars, 22.1% of vans, and 4.7% of taxis are carburetor
vehicles. Around 9% of the vehicles in Tehran are responsible for the production
of almost 400 tons pollutants annually.[127] Other reports demonstrated that cars
are responsible for 80% of air pollution. Unpublished data show that a motorcycle
produces air pollution 60 times more than a standard car. Based on reports, annual
average of air toxicants including PM 10, SO2, NO2 and O3 in Tehran capital city of
Iran with around 8.3 million inhabitants were 90.58, 89.16, 85, and 68.82 μg/m3,
respectively. These values are more than standards defined by EPA and WHO.
Therefore, as expected, air pollution is the main casualty of excess 2194 out of
total 47284 deaths in a year. According to a recent report, SO2, NO2, and O3,
respectively, have caused about additional 1458, 1050, and 819 cases of total
mortality in 2011.[128] According to an official report in 2013, air pollution leaves
almost 4,460 deaths annually only in Tehran.[129]
Reports of the World Bank in 2005 show that mortality due to urban air pollution
in Iran has led to about 640 million dollars annual losses which contribute to
0.57% of the gross domestic product.[130] Another report has also shown that Iran
is the world's third main polluted country in the world, which results in 16 billion $
annual loss for the country.[16] Many regulatory programs including planting
projects have been developed to reduce urban air pollution in Iran, but due to lack
of enough stewardship and standardization of new technologies including those
related to car engines and also nonstandard energy production, no significant
output has been obtained so far.[17]
Practical measures to reduce air pollution in Iran
The industrialization of societies is necessary to develop, but a long-term health
problem and ecological impacts of such growth should always be considered prior
to imposing a large financial burden on the societies. Therefore, it is suggested to
adopt a balance between economic development and air pollution by legislating
policies to control all activities resulting in air pollution.[131,132,133] There are
some temporary but not trustworthy strategies to reduce air pollution in Iran. For
example, increasing the price of fuels, planting trees around and inside the city,
replacing old cars with modern ones, and increasing road taxes and car insurance
may reduce the amount of air pollutants, but in order to keep the constancy or even
optimization, these strategies should be continued. The most air-polluted capital
cities of Asia are Delhi and Tehran.[134] Causes of air pollutions including cheap
and low quality of vehicle's fuel particularly gas oil, nonstandard motor engines,
inappropriate public transport, overuse of fossil fuel, lack of public awareness and
transparency, legislation, and cooperation between different departments and green
societies are similar in the two cities. Therefore, urgent and concerted actions at
national and international levels are required.
Some mega capital cities in the other countries like London and Tokyo have
controlled their air pollutions over the years following appropriate legislations and
strict controls, whereas moving the capital cities in India and Pakistan in the last
century have not solved the problem of air pollution in the long term in these
countries. Therefore, moving capital city will not solve the problem of air pollution
and only reduces the problem in the short term. Some recommended strategies to
reduce the air pollution in Iran are summarized as the followings:
 Standardization of vehicle's fuel as much as possible and also finding a new
source of energy for motor engines has attracted great attention. A great part
of emission comes from vehicle exhaust, especially those which use diesel
and gasoline. Using other clean source of energy such as compressed natural
gas (CNG), liquefied natural gas (LNG), and alcohol is of great interests.
Hence, exhorting researchers and also companies in the era of interest to find
a way for replacing petrol and other fossil fuels with new suitable power
generation sources will be beneficial.[135,136] Expanded of more CNG and
LNG stations in big cities of Iran and producing more vehicles using CNG
and LNG are recommended
 Standardization of motor engines and manufacturing engines with low fuel
consumption is another strategy to reduce the level of air pollutants. Surely,
motor vehicles will not use fossil fuel and derivatives anymore in the near
 future. Recently, some car makers in Japan and Western countries have
made electrical cars that use electricity from a battery storage for low speeds
which is usually enough for driving inside the cities with traffic and/or
controlled speeds. Hence, designing new motor engines, companies of
interests should look forward.[137] This might be implemented in Iran in the
future
 Improving public transportation systems by using more subways (metro),
trams, and electrical bus routes. Reducing the costs for the people who are
using such systems is an optimal solution for lowering air pollution.[14] The
people and governments will gain profits from reducing air contaminations
in the long term, both economically and in cases of health issues.
[138,139,140] At the present, there are only limited metro lines in Tehran,
Mashhad, and Esfahan. It is recommended to expand the metro lines in these
cities. Trams and electrical buses have unfortunately not been established in
Iran. They should be implemented soon in big cities of Iran
 Increasing the cost of fuel in Iran can be considered as an effective solution
to reduce the proportion of air contaminants. According to the report by
Barnett and Knibbs, higher fuel price is associated with lower air pollution
level[141]
 Imposing penalties for polluting industries and implementing low tax policy
for clean technologies. Applying more taxes on automobiles in Iran,
particularly on those older than 20 years to distinguish between dirty and
clean vehicles. The government should establish exhorting plans for car
makers and other producers who adhere to environmental standards.
Moreover, exhorting plans should be designed for all sources of emissions.
These plans may contain discount on taxes or other financial supports for
customers and producers
 Since the phenomenon of air pollution was a global issue over the centuries
since the industrial revolution, it is proposed to establish an interdisciplinary
academic field on air pollution. It is also suggested that more
communication and collaboration between specialists in different sciences
including toxicology, environmental health, analytical chemistry, mechanics,
and applied physics will be performed
 Continuous monitoring of air quality, designing and developing tools to
identify the pollutants, finding the origin of the particles, and the use of
 particulate filter for diesel engines and other nonroad cars are other
suggested practical approaches to reduce air pollution
 Extensive media campaign to increase public awareness about air quality,
environmental, and public health issues.
Inadequate legislation and also a lack of appropriate policies in Iran result in higher
levels of environmental pollution and its impact on the incidence of diseases,
which will undeniably impose a heavy financial burden on the community.
Increasing risk of diseases due to air contamination has necessitated defining the
standard values for air quality and also a normal range for pollutants and daily
control of air pollution. Thus, monitoring air quality plays an important role in
developing regulatory policies.[142] These should be implemented in all big cities
of Iran.
Regulatory programs should apply high taxes per unit of emission not only as a
penalty for air polluters but also should give rise to the cost of pollution for them in
order to ensure the efficient reduction of pollutants. Final achievement is to reduce
the pollution and not only paying the cost of damages by polluters.[143]
Advantages and breakpoints of these strategies should be carefully documented.
Tax on vehicles is the most controversial issue in controlling and management of
air pollution. It would be helpful providing all necessary facilities including
subway, and other transportation systems prior to applying penalties. In other
word, taxes should be applied, but public transportation systems should be
improved, and also its cost should be reasonable enough.
It is important to balance between all suggested strategies, and discuss all aspects
of each plan. Each of these controlling policies has an impact on each other and
also on the society. Ideally, an optimum solution for the problem of air pollution is
that in which no additional problem resulted from controlling policies impose on
the society. Therefore, a suitable controlling policy should contain penalties for
each unit of air pollutants’ emission. The sources of emission vary from small unit
of cigarettes to large volume of emission from motor engines of automobiles and
industrial activities.[144]

CONCLUSIONS AND RECOMMENDATIONS

Air pollutions have major impacts on human health, triggering, and inducing many
diseases leading to high morbidities and mortalities, particularly in the developing
countries such as Iran. Therefore, air pollutions control is vital and should be on
the top of priority list of the governments. The policy makers and legislators in
these countries must update all laws and regulations related to air pollutions.
Coordination between different departments involving in air pollutions must be
leaded by a powerful environmental protection organization. An effective
environmental protection organization should have enough budgets for
administration, research, development, monitoring, and full control of the
environment including air pollution.

Financial support and sponsorship

Nil.

Conflicts of interest
The authors have no conflicts of interest.

AUTHORS’ CONTRIBUTIONS
AGA, BRZ, and MBM contributed in study concept, design, and critical revision
of the manuscript. AGA and BRZ participated in the drafting of the manuscript.
MBM contributed in revision and final approval of the manuscript.

Article information
J Res Med Sci. 2016; 21: 65.
Published online 2016 Sep 1. doi: 10.4103/1735-1995.189646
PMCID: PMC5122104
PMID: 27904610
Adel Ghorani-Azam, Bamdad Riahi-Zanjani, and Mahdi Balali-Mood

Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical

Sciences, Mashhad, Iran
Address for correspondence: Prof. Mahdi Balali-Mood, Medical Toxicology Research Center,
School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. E-
mail: ri.ca.smum@mdoomilalab
Received 2016 Jan 24; Revised 2016 Mar 1; Accepted 2016 May 24.
Copyright : © Journal of Research in Medical Sciences
This is an open access article distributed under the terms of the Creative Commons Attribution
NonCommercial ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the
work non commercially, as long as the author is credited and the new creations are licensed under
the identical terms.
This article has been cited by other articles in PMC.
Articles from Journal of Research in Medical Sciences : The Official Journal of Isfahan University of
Medical Sciences are provided here courtesy of Wolters Kluwer -- Medknow Publications

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